3150 W LINCOLN AVE (5)Permit Types
BLD ELE MEC PLM
X X X X
Permit Plumber: 9MA 2244619
Issued: 02/28/2023
www.anaheim.net/building
(714)7654626
Quarter Section: 9
CITY OF ANAHEIM
BUILDING DMSION
200 S. ANAHEIM BLVD.
(714) 765 -5153
Site Address: 3150 W LINCOLN AVE 140, ANAHEIM, CA 92804
Legal Description: S TWP 4 RGE 11 SEC 14 T 4 R 11 SEC 14 POR NE1/4
APN:13528119
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to selfansure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the labor Code, for the performance of the work for which this permit is issued.
I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which
this permit is Issued. My worker's Compensation insurance carrier and policy are:
Cartier: STATE COMPENSATION INSURANCE FUND Policy No.: 1962693 Expiration Date: 10/26/2022
Name of Agent:
Phone No.:
I certify that the performance of the work for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the
worker's oo pensation laws of California, and agree that, d I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code I s orthwith comply with those provisions.
OZ -12- (2 Z
Sig re of App cant Date
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
1 hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is Issued
(Sec.3097.Civ.C):
Lender's Name:
Lenders Address:
LICENSED CONTRACTTR'S DECLARATION:
1 hereby affirm under the pe Ity of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my li nse Is in full force and effect.
0 2z'< 2
Con cr Sidnitute Date
NUMBER EXPIRATION DATE LICENSE TYPE IS
469215 021 2023